Informed Consent for Counselling/ Psychotherapy

Introduction

Welcome! This document outlines the important details regarding the counselling services I offer in my private practice. Please read this information carefully and ask any questions you may have before signing below. By signing this form, you acknowledge that you have read and understood this information and that you have had all your questions answered. If you elect to use your insurance benefits, as described in the section below called Insurance Reimbursement, then by signing this form you are also giving me permission to share your information with your insurance company.

About Me

My name is Sandra Cecilia Medina Acosta, and I am a registered clinical counsellor in British Columbia, Canada.

My license number is 19708.

Services Offered

  1. I provide individual therapy for [adults (ages 18+), couples and family counselling experiencing a variety of psychological challenges.

  2. I do not offer medication management and court-ordered evaluations.

Psychotherapy

  1. Psychotherapy is a collaborative effort that requires active participation from you.

  2. The approach used will vary depending on your needs and it may involve discussing uncomfortable topics.

  3. There are no guarantees about the outcome of therapy, but studies have shown psychotherapy to be helpful to those who undergo it.

Benefits and Risks of Therapy

  1. Therapy requires a significant investment of time, money, and energy. Therapy can be a helpful and effective way to address emotional and behavioral difficulties.

  2. Potential benefits of therapy include improved mood, reduced stress, better coping skills, and enhanced relationships.

  3. However, therapy can also involve some emotional discomfort as you explore challenging issues.

  4. Throughout any therapy sessions, I encourage you to ask questions. Also, feel free to seek a second opinion at any time.

Confidentiality

  1. All information discussed in therapy sessions will be kept confidential, unless you give me written permission to share such information, with some exceptions as outlined below.

  2. I may be required by law to report suspected abuse or neglect, for example regarding children, elders, or disabled adults. [Please note: Mandatory reporting laws vary by state. In some provinces, not all suspected abuse would be mandated for reporting by law. It is always recommended that you review the relevant laws and regulations in the state(s) you are practicing concerning your province’s specific mandatory reporting requirements.

  3. I may also be required to disclose information if compelled by a court order.

  4. If I believe you may harm yourself or others, I may need to take steps to ensure your safety or the safety of others.

  5. I may consult with other professionals about your case to help provide you with appropriate care. If I do such consultations, I will make every effort to avoid revealing information that could identify you to maintain your privacy.

  6. If you use your insurance benefits, I

  7. must share clinical information about you as described in the Insurance Reimbursement section below at the request of your insurance company.

  8. If you are concerned about confidentiality in any situation, please bring it to my attention.

Fees

  1. My standard fee for a individual therapy session is 175 CAD for 50 minutes.

  2. My standard fee for couples or family therapy sessions is 195 CAD for 50 minutes.

Additional Fees:

  1. Additional services, including the list below, will be billed at [rate per hour].

  2. Report writing

  3. Telephone conversations at your request

  4. Attendance at meetings with other professionals per your request

  5. Preparation of records or treatment summaries

  6. Time spent performing any other service you may request of me and to which I agree

  7. Tasks under one hour will be pro-rated (meaning the cost will be calculated proportionally to the time spent on the task and not the full hourly rate).

  8. Legal Matters:

  9. You are responsible for my professional time if legal matters require my participation, even if I am subpoenaed.

Payment

  1. I accept payment by credit/ debit card or e-transfer.

  2. Payment is due at the time of service unless otherwise agreed upon.

  3. I do not currently accept insurance; however, I can provide you with a detailed receipt that you may submit to your insurance company to seek reimbursement.

  4. If you choose to use insurance, please be aware that you are responsible for any copay, coinsurance, or deductible associated with your plan. If your insurance denies your claim, you will be responsible for the total amount of my fees.

  5. There is a 50% fee for cancellations with less than 24 hours' notice.

  6. If your account is unpaid after 30 days, I may use legal means, such as the help of a collection agency, to collect payment.

Insurance Reimbursement

  1. Understanding your insurance coverage is important for setting realistic treatment goals.

  2. I will try to help you navigate your insurance benefits and maximize coverage, but you are ultimately responsible for payment.

  3. Your insurer may require authorization before providing reimbursement and may limit the number of sessions that are covered by insurance. Should you request more sessions beyond your insurance coverage, you would be responsible for the total amount of those sessions.

  4. I recommend contacting your insurance company directly and in advance of our first session to understand your specific mental health coverage benefits and any limitations or pre-authorization requirements.

Choosing not to use your insurance for some or all your care. You have the right to pay

for services yourself to avoid these limitations and potential privacy concerns associated with using your insurance.

Your Rights

  1. You have the right to participate actively in your treatment and make informed decisions about your care.

  2. You have the right to ask questions and request clarification at any time.

  3. You have the right to terminate therapy at any time.

  4. You have the right to seek a second opinion.

  5. You have the right to access your treatment records, with some exceptions. Please let me know if you would like to discuss it.

Contacting Me

  1. When you contact my office, you are welcome to leave me a message, and I will make every effort to return your call.

  2. If you cannot reach me and require immediate help, call 911.

  3. In case of an extended absence on my part, I will provide you with contact information of a colleague who may be able to provide you with services.

My Responsibilities

  1. I am committed to providing you with competent and ethical psychological care.

  2. I will respect your privacy and confidentiality.

  3. I will discuss the limitations of my expertise and refer you to another provider if necessary.

Agreement

By signing below, you acknowledge that you have read and understood this Informed Consent document, that you have had all your questions answered to your satisfaction, and you consent to the releases of information described above. You agree to participate in therapy voluntarily.


Sandra Cecilia Medina Acosta

MA/RCC

MedShine Therapy Group